AlumierMD Consultation Form

Name

Post code and address

Phone number

Email address

example@example.com

Would you like to keep in touch via our newsletter?

Have you been referred from Colours Model Agency?

I am currently using or have used Accutane (isotretinoin) in the last six months

I am pregnant or nursing/lactating

I have allergies

I have a skin infection/open wound in the treatment area

I am allergic to aspirin (acetylsalicylic acid)

I have been exposed to the sun or used a tanning bed in the last 3 weeks

I am currently using sunless tanning products

I am using any prescription or non-prescription retinoids (eg. retinol, Retin-A®, Tazorac®)

I have used skincare products that caused an adverse reaction

If you answered YES to any of these, please explain further

What is the ethnic background of your parents?

Do you have any medical issues?

What is the main reason for your enquiry today?

Which of these statements is most applicable to you?

Have you had an aesthetic consultation or treatment before?

How often do you think about having an aesthetic treatment?

When I think about my appearance, I feel | look- Please tick three

On a scale of 1 to 10, 1 being desperately unhappy and 10 being extremely happy, how satisfied are you with your appearance?

On a scale of 1 to 10, 1 being desperately unhappy and 10 being extremely happy, how satisfied are you with your skin?

After treatment I would like to feel-Please tick three

What are your main skin concerns?

When did you first notice your concern?

Which of these apply to your skin?

Do you notice your skin concern gets worse at any time of the day/month/year?

What is your current skincare routine?

How is your current skincare helping your skin?

Are there any specific products you would like to try?

Which of these in-clinic treatments interest you?

How did you hear about us?

Front face

Right side

Left side

Preferred contact details

Signature

Once form is completed please email sayhi@hwfglow.co.uk or DM message HWFGlow on instagram to discuss the first step to your Skin Transformation..

Looking forward to our journey togeather, getting you to glowing skin health and wellness goals.

AlumierMD Skin Transformation Consultation